ASSIGNMENT AND RELEASEI certify that I, and/or my dependent(s), have insurance coverage with Name of Insurance Comapny(ies) and assign directly to AHS Medical Group all insurance benefits, If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
IN CASE OF EMERGENCY, CONTACT
Pain and Numbness Scale 0-10
Daily Activity Impairment
Select the number that indicates how you feel on a daily basis 0=no difficulties 5=moderate difficulty 10=severe or unable to perform